Community Kids: Child Intake Survey
Please answer each of the following questions so that we reliable information about you in case of an emergency and to improve your experience with Community Kids.
What is today's date? *
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What's your FIRST name? *
Your answer
What's your LAST name? *
Your answer
What is your age?
What is your birthday? *
MM
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DD
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What is your street address? *
Your answer
What is your zip code? *
Your answer
What is the FIRST name of your legal guardian and/or parent? *
Your answer
What is the LAST name of your legal guardian and/or parent? *
Your answer
What is the phone number to reach your legal guardian and/or parent? *
Please format your phone number as xxx-xxx-xxxx.
Your answer
What does your legal guardian and/or parent speak fluently? Check all that apply. *
Required
What is the best way to contact you? ( Ex. text, snapchat, email, facebook messenger etc.. What is your username/ number?
Your answer
Do you have allergies? If yes, please list under the other...
What are your siblings' names that attend the program AND live with at the same house as you? If you do not have any siblings that meet those qualifications, please write NONE.
Your answer
What is the name of your school?
Your answer
What is your personal belief system? *
What is your FAMILY's belief system (not necessarily your own)? *
Would you be interested meeting weekly with a Community Kids mentor outside of Community Kids Tuesday nights?
If you answered yes above, is there an adult leader you would prefer to meet with? If so, who?
Your answer
What frequency of your church attendance (outside of club) during an average month?
What is the name of your church? If you do not have a church you attend yet, please type NONE.
Your answer
Would you be interested in attending a local church on Sunday?
Why did you decide to attend Community Kids? Check all that apply.
What are activities you enjoy? Check all that apply.
What program(s) do you plan to attend with Community Kids? (Check all that apply)
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